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Women’s Experiences of Nurse-Midwifery Presence During Childbirth

Women’s Experiences of Nurse-Midwifery Presence During Childbirth. Presenter: Lauren P. Hunter, PhD, CNM Ph: 858-454-9033 email: lhunter@mail.sdsu.edu Affiliation : San Diego State University School of Nursing STTI Chapters: Gamma Gamma, Zeta Mu

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Women’s Experiences of Nurse-Midwifery Presence During Childbirth

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  1. Women’s Experiences of Nurse-Midwifery Presence During Childbirth Presenter: Lauren P. Hunter, PhD, CNM Ph: 858-454-9033 email: lhunter@mail.sdsu.edu Affiliation : San Diego State University School of Nursing STTI Chapters: Gamma Gamma, Zeta Mu Funding: San Diego State University Faculty- Grant-In –Aid # 242204

  2. Study Purpose • To measure postpartum women’s experience of one aspect of nurse-midwifery care, positive presence, during labor and birth in a hospital setting.

  3. Research Questions Did predominately Latinawomen who were attended by nurse-midwives in a hospital based nurse-midwifery service perceive a positive nurse-midwife presence during their childbirth experience? What effect did the environmental setting either in hospital birth center (IHBC) or in hospital standard labor and delivery unit (SL&DU) have on the degree of positive nurse-midwifery presence experienced by women?

  4. Research Questions Was there a relationship between the amount of positive nurse-midwifery presence experienced by women based upon a woman’s demographic variables, such as ethnicity, length of labor, parity, or organizational factors such as number of nurse-midwifery providers? Was there a relationship between the number and type of personal labor support persons present, such as family members, significant others, or doulas, and the degree of positive nurse-midwifery presence experienced by the woman?

  5. Research Questions Was there a relationship between the use of various types of coping/comfort techniques or medication for pain relief and the degree of positive nurse-midwifery presence experienced by the woman?

  6. Conceptual Definition of Midwifery Positive Presence • “the extent to which the nurse-midwive’s response to the laboring woman encompasses the high touch qualities of nurturance, intuitive awareness, sensitivity, personal attention, knowledge, professional expertise, presumed validity of the individual woman’s subjective experience” • “reflects the one-on–one personal attention and constant availability of the nurse-midwife for the woman in labor” (1p. 44)

  7. Conceptual Definition of Midwifery Positive Presence • Derived from qualitative interviews with women that received CNM care (1) • The definition was validated using theoretical indexing from the literature (1)

  8. Literature Review • Essential hallmark of the ACNM is the value of therapeutic presence (2) • Three American N-M studies (3-5), one metasynthesis (6) and one extensive literature review (7) found presence to be essential from midwive’s and women’s perspectives • Further qualitative studies from 1990 –2005 verify that the definition remains remains valid from women’s perspectives (8-25)

  9. Study Design • Descriptive • Correlational • Non-Probability Sample

  10. Midwifery Positive Presence Index Instrument (MPPI) • 29 item 5 response Likert Scale (max score =203) • Unidimensional scale based on the original conceptual definition of positive presence • Pilot tested on 15 women (Birth Center) • Chronbachs Alpha = .92 • Construct Validity = .77 • Item to Item Correlation Matrix =.42-.69 • Test Retest = .99 • Spearman Brown = .90

  11. Midwifery Positive Presence Index • Further Testing: • 89 low risk postpartum women (BC and Hospital) • Construct Validity = .64 • Principal Components Analysis (Theta Coefficient = .92) • Content Validity re-verified with a sample of PP women (post test focus groups) • Cronbach’s Alpha = .92

  12. Sample of MPPI Items • The nurse-midwife gave me reassurance when things got tough • The nurse-midwife’s touch was comforting • The nurse-midwife was an expert at what she/he did • The nurse-midwife helped me to work with what I was feeling

  13. Setting for Current Study • Low risk postpartum women • Large southwestern hospital • In-Hospital Birth Center • Standard Labor and Delivery Unit • CNM Service 14 CNM’s (10 FT and 4 PT) • 100-125 births /month

  14. Data Collection • Recruitment: • Prior to Discharge • Bilingual Flyer • Verbal Study Description • Bilingual RA • 30 Minutes of Time • Written Consent/Voluntary Participation

  15. Sample Characteristics (N=238) Range MeanSD Age 14-41 25.36 5.97 Gestation 38-42 39.28 1.84 Labor (Hr) 1-41 8.51 6.84 G P 1-13 2.36 1.64 Presence47-203 186.2 21.7

  16. Sample Characteristics (N=238) Gravida/ParityFrequencyPercent (%) Primiparas 87 36.7 Multiparas 139 58.7 Grand Multip 11 4.6

  17. Sample Characteristics (N=238) EthnicityFrequencyPercent (%) Hispanic 176 73.8 Caucasian 46 19.4 Other 14 6.8 Setting IHBC 100 43.1 SLDU 100 43.1 Transfer 38 13.8

  18. Sample Characteristics (N=238) Number ofFrequencyPercent (%) CNM’s One 58 24.0 Two 94 39.7 Three 49 20.7 Four 25 10.5 Five 9 3.8 Six 2 .8

  19. Place of Birth Was Significant ANOVA (F (2,221) = 3.69, p< .03) Pair Wise Comparisons • Presence MeanSD • IHBC 189.92 15.35 • Transfer 191.55 12.91 • SLDU 180.53 27.85

  20. Comfort/Coping Techniques

  21. Comfort/Coping Techniques

  22. Comfort/Coping Techniques Breathing Techniques Were Significant ANOVA(F (1,224) = 7.46, p =. 007) • Breathing Tech MeanSD 189.82 16.79 • No Breathing Tech 182.26 25.72

  23. Comfort/Coping Techniques Music Therapy Was Significant ANOVAF (1,224 = 3.83, p = .05) • Music Therapy MeanSD191.68 12.82 • No Music Therapy 181.35 26.55

  24. Not Significant

  25. Support Persons in ChildbirthNot Significant SupportPersonFrequency (%) • Husband/Partner 192 (81.0) • Mother 64 (27.0) • Doula 50 (21.1) • Sister 38 (16.0) • Other Person 32 (13.5) • Female Friend 23 (9.7) • Mother-in-law 22 (9.3)

  26. Internal Consistency • Present Study/Cronbach’s Alpha = .856 • Original Pilot Test/Cronbach’s Alpha = .92 • Original Study/Cronbach’s Alpha = .92

  27. Conclusions • Generalizable to: postpartum, low risk , young, primarily low income, Latina women • A high level of nurse-midwifery positive presence (186.2) was perceived by women despite today’s current childbirth milieu

  28. Implications for Practice • Women focus on the content of the care provided more than the model of care • Quality of interaction is probably more important than the amount of time spent with women • Encourage the continued use and expansion of nurse-midwives in women’s health care

  29. Implications for Practice • Increase the number of in-hospital birth centers • Smaller case loads of patients during childbirth so nurse-midwifery presence can be even more therapeutic • Breathing techniques and music therapy are helpful adjuncts in midwifery care • Husbands, and female relatives should also be encouraged to provide support

  30. Future Research • Examine the MPPI Index: • in other patient populations • different midwifery services and settings • Examine the relationship of midwifery presence to overall satisfaction with labor and birth and other variables of midwifery care

  31. References • 1. Lehrman EJ. A theoretical framework for nurse-midwifery practice. Unpublished doctoral dissertation, The University of Arizona, Tucson, AZ. 1988. • 2. American College of Nurse-Midwives. Philosophy of the American College of Nurse-MidwivesWashington DC: ACNM, 2004. • 3. Kennedy H. The essence of nurse-midwifery care. J Nurse-Midwifery 1995;40:410-417. • 4. Kennedy H. A model of exemplary midwifery practice: Results of a Delphi • study. J Midwifery Women's Health 2000;45:4-19. • 5. Thompson JD. Oakley D. Burke M. Jay S. Conklin M. Theory building in nurse-midwifery: The care process. Journal Nurse-Midwifery 1989;34:120-130. • 6. Kennedy H. Rousseau A. Low L.An exploratory metasynthesis of • midwifery practice in the United States. Midwifery 2003;19:203-214.

  32. References • 7. Hunter LP. Being with Woman: A guiding concept for the care of laboring • women. JOGGN 2002;31:650-657. • 8. Berg M. Lundgren I. Hermansson E. Wahlberg V. Women's experience of the encounter with the midwife during childbirth. Midwifery 1996;12:11-15. • 9.Flemming V. (1998). Women-with-midwives-with-women: A model of • interdependence. Midwifery 1998;14:137-143. • 10 Frazer D. Women's perceptions of midwifery care:A longitudinal study to • shape curriculum development. Birth 1999;26:99-107. • 11. Frazer D. Murphy R. Worth-Butler M. A model of competence: The • consumer's perspective.Br J Midwifery 1996;4:576-580. • 12.Halldorsdottir S. Karlsdottir S. Empowerment or discouragement: Women's experience of caring and uncaring encounters during childbirth. Health Care Women Int1996a;17:361-379. • 13. Mosallam M. ThomasL. Ezimokhai M. Women's attitudes towards • psychological support in labour in the United Arab Emirates. Archives Gynecol Obstet 2004;269:181-187.

  33. References • 14. Bluff R. Holloway I. They know best: Women’s perceptions of midwifery • care during labor and birth. Midwifery 1992;10:157-164. • 15. Halldorsdottir S. Karlsdottir S. Journeying through labour and delivery: • Perceptions of women who have given birth. Midwifery 1996b;12:48-61. • 16. Hallgren A.& Kihlgren M. Olsson P. Ways of relating during childbirth: An ethical responsibility and challenge for midwives. Nursing Ethics 2005;12:606-621. • 17. Tarka M. Paunonen M. Social Support and its impact on mothers’ • experiences of childbirth. J Adv Nursing 1996;23:70-75. • 18. Walker J. Hall S. Thomas M. The experience of labour: A perspective from those receiving care in a midwife-led unit. Midwifery 1995;11:120-129. • 19. Walsh D. An ethnographic study of women's experience of partnership • caseload midwifery practice: The professional as a friend. Midwifery 199;15:165-176.

  34. References • 20. Waldenstrom U. Borg I. Olsson B. Skold M. Wall S.. The childbirth experience: A study of 295 new mothers. Birth 1996;23:144-153. • 21. Janssen B. Wiegers T. Strengths and weaknesses of midwifery care from the perspective of women. Evid Based Midwifery 2006;4:53-59. • 22. Lavender T. Walkinshaw S. Walton I. A prospective study of women's views of factors contributing to a positive birth experience. Midwifery 1999;15:328-334. • 23. Too SK. Do birthplans empower women? A study of their views. Nurs Stand1996;10:33-37. • 24. Blix-Lindstrom S. Christensson K. Johansson E. Women's satisfaction with decision-making related to augmentation of labour. Midwifery 2004;20:104-112. • 25. Lundgren I. (2004). Releasing and relieving encounters: Experiences of pregnancy and childbirth. Scand J Caring Sci2004;18:368-375.

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